Healthcare costs are soaring and fingers can point to a multitude of causes: the aging population, technological and clinical
advances, a more-is-better philosophy, to name just a few. In 2011, the United States spent $2.7 trillion—nearly 18 percent
of GDP—on healthcare. On a per capita basis, that amounts to $8,400 for each citizen, up from $4,700 in 2000. The single largest
payer, Medicare, paid over $549 billion of these 2011 costs, one-quarter of which were incurred during the last year of life.
The quest for the miracle treatment or cure does not come cheap. And a solution to the emotionally and politically charged
issue of dying will not be easy.
The debate is highly charged. Rhetoric flies about "death panels" while the "R word"—rationing—is invoked to halt any discussion
about managing the cost curve. But the problem is not unique to our side of the pond. In the United Kingdom, the National
Institute for Health and Clinical Excellence (NICE) recently rejected Roche's melanoma drug Zelboraf, saying the cost is too
high for the limited benefit it provides to patients with few other options. Zelboraf does not stand alone in the NICE category
of end-of-life drug rejections. But cancer patients in England, unlike their brethren in Scotland, Wales, and Northern Ireland,
have been granted a temporary reprieve. Drugs rejected or not yet evaluated by NICE may be accessed through the Cancer Drugs
Fund, a short term fund launched in April 2011 and scheduled to run through March 2014 when a value-based pricing plan for
NHS reimbursed medicines is to be implemented.
Might this piecemeal approach be a panacea to the problem of paying the high cost of treatments for those with severe, terminal
stage conditions? It's doubtful. Even in the unlikely event a plan could be developed to satisfy all stakeholders, the confusion
about valuing end-of-life care requires more than just a single bandaid, or a better way of building a better diagnostic coding
base for the major killers in cancer. More issues have to be addressed. For the sake of simplicity, let's bucket these issues
into three: communication, compensation, and constructive innovation.
Communication: the doctor-patient relationship
It's easy to focus on the high price of goods and services, but communication seems a fitting place to begin a discussion
about cutting costs. Certainly the issue of patient preference has made the news, and it pertains to all patients, all states
of disease and wellness, and all stages of care. Bottom line: Quality care must incorporate patient preferences. With the
creation of the Patient-Centered Outcomes Research Institute as part of the Patient Protection and Affordable Care Act of
2010, we've put patients front and center where they belong. Hopefully this will improve awareness of the needs of the sickest
patients, because when it comes to end-of-life care, the patient is most often left out of the equation.
Indeed, the Agency for Healthcare Research and Quality has estimated that fewer than 30 percent of Americans have advanced
health directives, including millions of people with debilitating chronic disease. Among vulnerable elders, only 15 percent
to 22 percent had preference information recorded in their medical records. Without knowing patient preferences for aggressive
treatment versus palliative or supportive care, it's tough to try anything less than the full basket of miracles. Physicians
and hospitals don't wish to be sued for failing to go the extra mile.
It's not only about advance directives, however. It's about receiving information and making informed choices. Peer-reviewed
literature indicates that patients tend to be too optimistic about their prognosis and response to therapy. Perhaps the underlying
problem is that fewer than 40 percent of cancer patients, even those for whom death was believed imminent, are told of their
prognosis or even the possibility of death. In one study, half of the patients with metastatic lung cancer who were within
two months of dying had not had a discussion with their doctors about the option of hospice care. With hope so fixed on the
horizon, starting a new chemotherapy regimen within a week or two of death is not unusual.
While education will likely not shift the situation entirely, there is reason to believe that better information will move
patients and families to more reasonable and less expensive choices. Choosing less aggressive treatment may result from the
new reality that comes with education, or as some research suggests, the choices may change if the patient's fear of abandonment
is mitigated. Knowing care plan alternatives and understanding that other care providers will be involved even if the patient
opts out of chemotherapy can result in lower costs.
Many doctors, however, say it's difficult to initiate conversations about prognosis and end-of-life decision-making. This
type of communication is not part of their skill set; they were trained to cure people, not let them die. Doctors need to
acquire this skill, for the sake of their patients and the national budget. Research indicates that patients who have had
conversations with their doctors experience less anxiety, receive less aggressive end-of-life care, and are unlikely to die
in an intensive care unit.
In her 2012 memoir, journalist Amanda Bennett writes of her marriage and her husband's end-of-life care. Terrance Foley died
in 2007 and both he and his wife clung to the hope offered to them by his oncologist. Pouring through medical records after
Foley's death, Bennett learned that many in the hospital disagreed with the oncologist's optimism, and the well-meaning staff
continued testing and treating although they knew Foley would soon be dead. Less than a week before Foley's death, a resident
spoke to Bennett about end-of-life choices and her husband's imminent passing. This was the first-ever conversation of this
sort she had. Foley was in the intensive care unit, slipping in and out of coma, and husband and wife never had a chance to
say goodbye. The emotional cost was high, and years later, while reviewing his records for her memoir, she learned about the
charges paid by insurance and wondered if they would have made different choices if only they had been informed.